The Grievances & Appeals Professional 2 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities
The Grievances & Appeals Professional 2 (formerly an Analyst role) assists team to further/support quality and compliance related goals. Analyze member/ provider Grievance and Appeals issues. Coordinating work activities. Often analyze work of others and/or is the primary administrative owner of a main process, program, product or technology. Works within broad guidelines with little oversight. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Required Qualifications
1-3 years of prior grievance and appeals experience
Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing
Strong analytical skills required
Strong data entry skills required
Experience handling multiple projects and assignments as directed by Management
Attentiveness to detail
Work At Home (WAH) – Temporary Due to COVID-19 emergency. Please note this permanent position allows you to work at home indefinitely until further notice. See additional information in section below.
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
Bachelor’s Degree
Strong knowledge in Microsoft Access or experience with SQL Server databases
Additional information
Schedule: Monday to Friday from 8 am to 5 pm, Overtime as needed per business need.
Training: 4 weeks remotely
Work Location (Address): This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date: 11430 NW 20th Street | Doral, FL 33172
Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government
Scheduled Weekly Hours40
To apply for this job please visit www.humana-spain.org.
